United Response - 66 & 66a Lemsford Road

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question inadequate. At this assessment the rating has changed to requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to the safe storage of medicines, infection prevention control and premises.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

We saw evidence that incidents and errors were investigated and reviewed for lessons that could be learnt and improvements implemented. For example, where staff had made medication errors these had been investigated, staff had been spoken to identify the root cause and when needed staff had undertaken a refresher course.

We also saw evidence that incidents were reviewed for root cause’s and staff were debriefed after to access the impact the incident had on them. The manager said that where possible debrief after incidents would also include the person being supported going forward.

A staff member said, “Managers do lesson learnt reviews, this are not about finding someone to blame but they are about finding the cause of what happened, they explain how it happened and what could have been done differently to avoid the situation.”

The provider did not always make sure documentation that is used for the safe transition across services was current and up to date. This means they did not always make sure there was continuity of care, including when people moved between different services.

The provider has a range of documents available to ensure continuity of care between services. However, their systems had not identified when these documents were not current or had missing information. For example, the service uses a personal health passport called the Purple Folder’. This is designed for adults with learning disabilities in Hertfordshire, to go with people to all medical appointments and hospital admissions to help doctors and nurses better understand the person’s care and needs. We found some important information had been transcribed into the health passport including for one person the need to administer a rescue medication for epilepsy care.

We also found the ‘emergency profile’ to be printed and accompany the person to hospital for unplanned events lacked the important information.

The manager was new in post and told us these documents would be reviewed as part of the service improvement plan.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

One staff member said, “We keep people safe by following health and safety procedures, our policies and our training.” Another staff member said, “Safeguarding means to prevent people from avoidable harm and abuse.”

Staff were able to explain the different types of abuse and how to report. Staff knew both the internal reporting processes and to report to external agencies if they felt action wasn’t taken.

Systems were in place for staff to record incidents, complaints and accidents. These were then reviewed by the seniors and the manager and where appropriate reported to the local authority safeguarding and CQC by way of statutory notification. Debriefs took place and lessons learnt reviews were shared with staff.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff members considered the full spectrum of risks such as physical, emotional, social, and environmental rather than focusing solely on clinical or immediate safety concerns. For example, staff spoke about the importance of engagement in activities and community access to help keep one person emotionally balanced reducing the risk of frustration and incidents that can occur when people are not empowered.

Risk assessments were person-centred, and were tailored to the situation, needs and preferences of each person. However, some detail within risk assessments needed to be more robust to ensure the most important and significant factors come first followed by the steps to mitigate the risks. The manager acknowledged this feedback and had started working on the identified risk assessments during the assessment.

The provider did not always detect and control potential risks in the care environment. They did not always make sure facilities supported the delivery of safe care.

We identified 12 windows above ground level without restrictors, allowing windows to be fully opened. Window restrictors are a legal requirement in residential care homes for windows above ground level. We brought this to the managers attention who assured us no one was at risk of falling but took immediate action to have the restrictors fitted the next day.

Whilst bathrooms were not unsafe, they lacked a homely feel with poor décor. In some cases, the wrong type of paint had been used on bath walls, and the paint was pealing as a result. Bathrooms felt like an undignified space, with oversized bin, poor cleaning and people’s personal items. The provider shared our views of the bathrooms and demonstrated they have been trying to resolve this with the housing association for some time. The provider was frustrated with the limitations on them to address the bathroom décor.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The provider implemented a training programme for all staff, covering key areas designed to enhance the quality of care offered to people and maintain robust health and safety standards. The training included safeguarding adults, dementia care, infection control, learning disability awareness, epilepsy awareness and medicines administration. The provider also checked staff competences for medicines including rescue medication for epilepsy treatment.

The manager told us they were in the process of introducing observational supervisions where staff will receive direct feedback based of observations of their practice.

A staff member said, “A lot of us were agency at first but we have been recruited to here now. When I came here, I loved it from the start, so when the chance came to apply, I took it. This is a really good place to work.” Another said, working here has been great, I can see improvements being made to care and staff training. We are compliant with our policies. We have improved our support through promoting people's independence.”

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We found bathrooms and areas of kitchens that were dirty and not clean. We discussed this with the manager who agreed action was needed to address this. The manager created a cleaning rota where staff sign off cleaning chores, and the manager will complete a daily walk around to spot check staff cleaning.

The provider did not make sure that medicines and treatments were safe and met people’s needs.

At the time of the assessment, we found medicines were not being stored in line with the manufacture’s guidance. This created a risk that medicines can lose their active ingredients and can make medicines lose its effectiveness or become unsafe. There was no risk assessment that covered the change made to how medicines were stored, therefore the provider did not fully assess the decision and risks to people.

We spoke with the manager who took immediate action to return the affected medicines to the pharmacy and replace the stock.